What is a coronary perforation?

Coronary Perforation: Definition, Classification, and Management

A coronary perforation is a breach in the coronary artery wall that extends through the full thickness of the arterial wall, allowing blood to extravasate outside the vessel lumen, which can lead to hemodynamic compromise, cardiac arrest, and death if not promptly recognized and managed. 1

Classification of Coronary Perforations

Coronary perforations are classified based on both location and severity:

Location-Based Classification

• Main vessel perforation: Occurs in the primary coronary artery
• Distal branch perforation: Occurs in smaller distal branches
• Septal collateral perforation: Occurs in septal collateral vessels
• Epicardial collateral perforation: Occurs in epicardial collateral vessels 1

Severity-Based Classification (Modified Ellis Classification)

• Type I: Extraluminal crater without extravasation
• Type II: Pericardial or myocardial blush without contrast jet extravasation
• Type III: Extravasation through frank (>1 mm) perforation 1

Risk Factors and Causes

Common causes of coronary perforation include:

• Wire perforation (especially with hydrophilic wires)
• Atherectomy procedures
• Aggressive balloon or stent sizing
• Complex lesions (calcified, chronic total occlusions)
• Advanced PCI techniques 2, 3

Patient-related risk factors include:

• Female gender
• Older age
• Lesion complexity 4

Clinical Presentation and Complications

Coronary perforation can lead to:

• Hemodynamic compromise
• Cardiac tamponade
• Cardiac arrest
• Death 1

In post-CABG patients, perforation may cause:

• Focal tamponade
• Cardiac chamber hematoma
• Bleeding above pericardial reflections into chest or mediastinum 1, 2

Immediate Management

1. Immediate balloon inflation proximal to or at the site of perforation for 5-10 minutes to tamponade the leak 2

2. Treatment based on perforation type and location:

   • Large vessel perforation: Covered stent implantation (polytetrafluoroethylene-coated stents have shown 92.9% complete sealing rate) 5
   • Distal vessel perforation: Coil or fat embolization, or novel techniques like cut balloon remnants 3, 6
   • Septal collateral perforation: Often self-limiting, may not require specific intervention
   • Epicardial collateral perforation: Requires aggressive management as they can lead to tamponade 2

3. Management of cardiac tamponade:

   • Immediate pericardiocentesis if tamponade develops 2
   • Reversal of anticoagulation 4

Post-Procedure Monitoring

• Close hemodynamic monitoring
• Serial echocardiography to assess for delayed effusion
• Monitoring for delayed tamponade (may occur several hours after procedure)
• Persistent chest pain after covered stent deployment requires immediate CT evaluation 2

Special Considerations

• In post-CABG patients, be alert for loculated hematomas or bleeding into mediastinum/pleural cavities 2
• Radiation exposure should be tracked and reported, especially if procedure exceeded 5 Gy 2

Documentation Requirements

For proper documentation of coronary perforations, it is important to record:

• Location of perforation
• Severity (Ellis classification)
• Likely cause (wiring, microcatheter advancement, ballooning, stenting)
• Management of the perforated segment
• Management of extravasated blood 1

Coronary perforation remains one of the most feared complications of PCI, but with prompt recognition and appropriate management using modern techniques like covered stents, the previously high rates of mortality and emergency bypass surgery have significantly decreased 5.